Enhancing Academic and Career Success for College Students with TBI:
VCU's Academic and Career Exploration-Individualized Techniques (ACE-IT!) Model

Preparation of this manuscript was supported by contract # CNI 03-214 from the Commonwealth Neurotrauma Initiative (CNI) Trustfund. The contents are the sole responsibility of the authors and do not represent the official views of CNI Trustfund.

INTRODUCTION

Through a combination of legislative, social and academic changes over the past 20 years, greater numbers of students with disabilities elect to pursue a college education today (Blackorby & Wagner, 1996; Gajar, 1992; 1998: Wagner & Blackorby, 1996). Eleven percent of undergraduate students reported having a disability in 1999-2000 (NCES, 2003). Additionally, results from a National Longitudinal Transition Study-2 from 1987-2001 reflect that growing numbers of students across all disability categories include higher education programs as transition goals. (Wagner, Cameto, & Newman, 2003). According to the Bureau of Labor Statistics projections for 2006, 18 of the top 25 occupations, those with the fastest growth, higher pay and low unemployment will require at least a bachelor's degree. (Berry, 2000). Students with disabilities seek a college degree with the hope of attaining greater earnings, benefits, social status, marketability, and career advancement.

As the number of college students with disabilities increases, a growing presence on college campuses includes students with brain injury (Ruoff, 2001). The highest incidence of brain injury occurs among youth and young adults between the ages of 15 and 24, traditionally when many are considering vocational options, applying to colleges, or beginning a postsecondary education program. The sudden onset of a brain injury may cause a severe interruption in the traditional completion of academic requirements and often results in a readjustment of career goals. Individuals successful in manual labor positions pre-injury may need to redefine a career goal involving less physical requirements post injury. Other individuals with professional career goals pre-injury may need to adjust their goals post-injury to focus on their altered strengths and abilities.

Although more students with disabilities are enrolling in college, these students are less likely to remain in college and receive a degree than those students without disabilities (Horn & Berktold, 1999). The retention issues as well as the steady growth in enrollees of students with disabilities generates interest on college campuses regarding how to meet the educational and career development needs of students. There is a growing body of literature studying the need for various models of service delivery on college campuses to serve students with disabilities (Getzel, Briel & McManus, 2003; Gugerty & Duffy, 2005; Getzel, Stodden, & Briel, 2001). This article discusses the common challenges of students with disabilities in higher education and describes a supported education/career planning model called Academic and Career Exploration-Individualized Techniques (ACE-IT!) used at Virginia Commonwealth University. The purpose of the model is to determine what specific academic and career interventions will enable students with traumatic brain injury (TBI), spinal cord injury, and other disabilities to meet their academic and career goals.

Academic & Career Challenges

Due to the complex nature of brain injuries, it may be months post injury or even longer before the educational problems associated with a brain injury can be identified or the impact on school performance determined (Clark, Russman, & Orme, 1999). Although the individual consequences of TBI vary greatly and depend on the student's pre-injury level of functioning, severity and location of injury, and recovery time post-injury, there are four primary domains of learning that are often affected (Keyser-Marcus, Briel, Sherron-Targett, Yasuda, Johnson, & Wehman, 2002). These domains include communication skills, concentration and attention, memory, and executive functioning all of which can significantly affect success in higher education and beyond into employment. As a result, students with TBI may have problems directing the implementation of support services. One of the greatest barriers is their inability to recognize their limitations and to seek help. Even when a student is able to recognize his or her ability to function effectively in an academic environment, he or she may not be able to use this information to design remediation strategies.

In addition to learning challenges, college students with traumatic brain injury encounter many of the same academic and career challenges that face other students with disabilities (Ruoff, 2001). These students now become one of potentially hundreds of students that are seeking services through a Disability Support Services (DSS) office on campus. Students are responsible for requesting their supports and services, providing documentation to receive these accommodations, and interacting with faculty to implement their supports. Along with these increased responsibilities, students with disabilities must also adjust to an educational environment much different than their secondary school experiences, including instructor-student ratio, less contact with instructors, expectations of higher levels of academic competence, fewer tests covering broader base of knowledge, changes in personal support systems, and greater expectations to achieve independently. These changes have in part contributed to students with disabilities feeling overwhelmed and unable to complete their advanced degree program, which results in low retention and completion rates (Getzel, et al., 2001).

Additionally, there are institutional factors that may impact students' ability to successfully remain in school to earn a degree. Because of the increased number of students with disabilities entering postsecondary programs, the range of services provided by postsecondary institutions are still relatively new and not yet well known by faculty members (Getzel, et al., 2001; Mellard, 1994; Minskoff, 1994; Wilson, Getzel & Brown, 2000). Faculty and other stakeholders may find it difficult to accommodate students simply because they lack an understanding of students' needs or familiarity with campus services (deFur & Taymans, 1995; Scott, 1996).

Students with disabilities need a solid understanding of their disability and the impact on learning, communication, and performance in daily life. Students also need the advocacy skills to address faculty and employer fears through the provision of educational information and accommodation solutions. Students with disabilities must determine if, when, and how to disclose disability to the university and an employer. Faculty members, administrators, and employers may have negative or prejudicial attitudes towards individuals with disabilities (Allen & Carlson, 2003; Greenbaum, Graham, & Scales, 1995; West, et al., 1993; Wilson, et al., 2000). In too many instances, students with disabilities feel that they do not belong in advanced educational programs because of the need to self-identify for specific services. As a result, students may elect not to disclose their disability to the university in order to avoid being labeled as having a disability (Gordon & Keiser, 1998; NCSPES, 2000b). Training, counseling, and resources need to be available to students in order to make an informed choice in this matter and to acquire the necessary skills to disclose effectively.

Not only do college students with disabilities face traditional academic challenges, the also lack the necessary worksite experiences to fully understand the impact of disability on career choice or to determine what strategies, technology, or supports might be needed on the job (Getzel, Briel, & Kregel, 2000). With extra effort being required to complete academic requirements, time may be minimal to coordinate workplace experiences such as part-time jobs or job shadowing. Traditional summer work opportunities may be replaced by the fulfillment of academic requirements. Ironically, many students with disabilities learn best through experiential learning, yet are excluded from established internship programs due to GPA requirements (Briel & Getzel, 2001).

Another factor to consider for career success is that many of the traditional classroom accommodations may not transfer to a work setting. For example, it is not reasonable for employees to regularly request extended time for assignments or ask that all directions be in writing. As students begin the pursuit for employment, it is important to look at how students can assume responsibility for their disability, compensate on the job, and manage the impact of the disability to increase productivity and efficiency. These skills include understanding the impact of disability on work performance, identifying workplace solutions or accommodations, and articulating this information to the hiring supervisor in an effective manner.

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MEETING THE NEEDS OF COLLEGE STUDENTS WITH DISABILITIES

To meet the educational and career support needs of students, disabilities support services offices across the country face the need to provide more varied and specialized services to meet the increased demand for these services. Typically these programs can be categorized by level of services offered as in minimal, moderate, or intensive (Brinckerhoff, et al., 1993; Mooney, 1996). Minimal programs offer general academic support services and developmental classes. Moderate programs have coordinated services, and students are fully included into their academic studies. An intensive program provides a specialized service component and an advocacy component. Some universities and colleges are testing new models of service delivery for all students, designed to provide more individualized and ongoing services to assist students to manage their educational program.

Virginia Commonwealth University's ACE-IT! Model

The expansion of services to assist students with disabilities in partnership with the DSS office is an approach that Virginia Commonwealth University (VCU) has developed. The idea for the model resulted from an evaluation of services and supports provided on the VCU campus that recommended an expansion of supports for students with disabilities. The development of this model uses supported education principles and is designed to study the educational and career interventions most effective for students with TBI and SCI.

The intent of the project, funded through the Commonwealth Neurotrauma Initiative (CNI) Trust Fund is to enhance services for college students with traumatic brain injury and spinal cord injury. The CNI Trust Fund resulted in collaboration with the state department of motor vehicles. The license renewal fee collected from individuals who had received a drunk driving offense ($25) was deposited in this fund enabling 13 projects designed to enhance services for individuals with TBI and SCI to be funded across the state.

Principles of the ACE-IT! Model

The model developed by VCU uses the principles of existing supported education models originally developed for individuals with psychiatric disabilities or attention deficit hyperactivity disorders. The principles of a supported education model emphasize a consumer-driven, individualized support system utilizing community and university resources. The model structures these resources around the students' career choice to help them meet both their short- and long-term goals (Cooper, 1993; Egnew, 1993; Unger, 1998). It was decided that the model at VCU would be designed to provide supports within the current disability support services structure on campus, using both university and community resources. This would enable students to receive services as part of their typical experience on campus.

COMPONENTS OF SUPPORTED EDUCATION PROGRAM

Linking with Community Resources

Mowbray and colleagues (1993) identified five components for building and implementing a supported education program. The first is establishing and using critical community linkages. Creating these linkages helps to blend community and university resources to provide a range of supports for students who may be in need of specialized services beyond those available only on campus. The ACE-IT! model has a strong emphasis on linking community resources to students while they are in college.

Recruiting Students

The second component identified is student recruitment (Mowbray, et al, 1993). It is essential that students with disabilities learn about the range of available supports and services on campus and how to get access. Several recruitment strategies are used to recruit students in need of a supported education program. Most of the student participants are recruited through the University's Disability Support Services Office (DSS) and identified by the DSS staff as needing more individualized and intensive services. Typically, these students are seeking assistance through the DSS office because they are failing in one or more classes, on academic probation, or significantly behind in their course work. Students are also referred to the program through faculty members, counseling center staff, students, or other staff on campus.

Identifying and recruiting students with traumatic brain injury on college campuses is not as straightforward as it may seem. It is likely that many individuals elect not to disclose their disability to the disability support services office for a variety of reasons. Students may not be aware of the impact of their disability on learning, may not want to identify as having a disability, or may not be aware of the process involved and the benefits of receiving accommodations. Information was disseminated throughout the campus using the University's web site, student organizations, student and university publications, electronic bulletin boards, and in residence halls. The program also provided information to community partners in rehabilitation, brain injury association newsletters, independent living centers, parent associations, and support groups to inform them of the supported education program. To reach more of the target population, the project initiated the development of a consortium of community colleges and universities to further assess the unique academic and career development needs of this particular population. The consortium consists of two historically black four-year universities, two community colleges, and one private four-year college.

Developing an Academic/Career Plan

The third component of the program is the intake of students (Mowbray, et. al, 1993). Specific services are designed around each student's expressed and documented need using an academic/career plan. The plan serves as a mechanism to help guide students through their academic course work and career preparation. A student-centered plan is generated that focuses on students's preferences and needs.

Implementing the Academic/Career Plan

The fourth component of the program is implementing the services and supports to address the needs identified on the plan. The VCU model is student-centered and self-directed. Student participants can determine the amount of assistance and support they receive. Students and program staff discuss how often they should meet to discuss any problems that may be occurring, or to follow-up on the effectiveness of the supports or strategies identified. If specific strategies are not working for a student, the staff and student meet to develop alternative methods and incorporate these changes in the student's plan.

AREAS OF PROGRAM SERVICES AND SUPPORTS

The ACE-IT! model targets five key areas when providing supports for students with traumatic brain injuries. The focus areas include identifying and promoting the utilization of effective accommodations, connecting students to existing campus and community resources, strengthening academic skills, exposure to technology, and gaining work experience.

Identifying and Using Accommodations

Students with acquired disabilities, such as those with psychological disorders, traumatic brain injuries, and health disorders, must develop a practical understanding of their disability and the impact on daily life. Often the recovery efforts for individuals with traumatic brain injury focus on physical aspects, with little attention paid to cognitive processes or interpersonal effects. Students may learn after receiving a failing grade that their ability to process, retain, and apply new information has changed. This awareness of the effects of the disability can occur after enrolling in a particularly difficult course or through an internship experience in which different demands placed on the student prove challenging. Discussing the individual experiences of students and providing resource information about brain injury is a first step in increasing awareness and acceptance of disability. Students with disabilities may also have difficulty obtaining and utilizing their accommodations. Reasons for not using accommodations include not knowing the process for receiving accommodations, being embarrassed about having a disability, or trying to be successful without using accommodations.

The development of self-advocacy skills begins with a foundation level knowledge of the disability and awareness of the practical impact in all areas of life. Students and staff need to include a review of recent neuropsychological evaluations to determine the best learning style for the student in order to build on his or her strengths. For example, an individual with strong visual memory and poor auditory memory may consider requesting a note taker for a classroom accommodation. Alternatively, he or she may find tape recording class lectures useful allowing for repeated listening to develop personal notes.

Connecting to Campus and Community Resources

The ACE-IT! model creates connections to community-based services and to the business sector. Establishing a link to the community through participation in support groups, rehabilitation services, and independent living organizations prepares students to understand and utilize the adult service system before exiting higher education. Connections to the business community take the form of creating informational interviewing opportunities, job shadowing and internship experiences. Because the supported education model provides services around a student's career choice, linking to the community becomes an important part of the supports provided.

Strengthening Academic Skills

Students with traumatic brain injury in higher education sometimes find that the academic strategies they used pre-injury are not effective post-injury. These students may be surprised when they receive their test scores, feeling that their test scores did not reflect their efforts in studying. Individuals with traumatic brain injury may need to explore new learning strategies post-injury to meet the demanding curriculum. Additionally it is often beneficial for some students to initially enroll in only one or two classes to further identify current skills. The VCU ACE-IT! model works with students to strengthen their academic skills by utilizing their strengths to compensate for the impact of their disability. Examples of the types of academic/career skills strengthened in the program are in Figure 2.

An example of how academic skills are strengthened is illustrated in the case of Joe, a student who acquired a traumatic brain injury in the midst of his college experience. Joe felt that he had spent sufficient hours reading and studying the class material; however, his test grades did not reflect his efforts. VCU staff and Joe began by analyzing a test that he had recently taken in order to identify any patterns of error. After analyzing the test, Joe realized that he was recognizing the information, but was not committing the information to memory. He was having difficulty with the vast amount of information he had to memorize. Learning strategies explored included active reading strategies, reviewing the accompanying textbook web sites and sample quizzes, developing flash cards for key terms, creating cell charts to organize information, and developing a constant review plan. Not only was Joe able to better organize the information hence making it easier to retrieve the information, but he also used the cell chart as a way to check his memory.

Exposure to Technology

A key component of the VCU ACE-IT! model is the exploration and utilization of technology to assist students with their academic coursework and performance on the job. In the last decade, there have been tremendous advances in the area of technology to enable individuals with disabilities to read, write, communicate, and work with greater ease and efficiency (National Organization on Disability, 2002; Langton & Ramseur, 2001; Senator, 2000). College students with disabilities need access to technology that promotes positive career outcomes; a medium to learn how to use the technology in the most effective way; and a seamless transition as students move from academia to career environments (Burgstahler, 2003).

As a result of implementing the program, staff members have found that a majority of students with brain injury have had little to no experience with assistive technology prior to entering college. Examples of the types of technology used in the program are in Figure 3. These types of technology are used in a myriad of ways depending on the task and each student's needs, strengths, weaknesses, and familiarity with technology.

During the development of the academic/career plan, the staff member and student decide if and what technology options might be the most suitable and effective in compensating for their disability. The technology is demonstrated and customized to meet the student's unique needs. Following the demonstration a practice session is held with the student to try the technology with the assistance of the program staff. This enables the student to learn how to correctly use the technology and to determine if it is suitable for the student's needs. It also increases the likelihood that the technology will be used by the student and not abandoned should the student encounter difficulties in using it. Should students face problems with the technology, the staff immediately meets with them to determine what are the issues and potential solutions. The use of technology has been applicable in the academic and work setting.

An illustration of how technology is explored and used in the program is in the case of Joan, who is a student with multiple disabilities, including TBI, attention deficit/hyperactive disorder, prior history of substance abuse, and depression. Joan had difficulties with time management. She wrote important information on scraps of paper but would often lose the pieces of paper or forget to check her notes, and hence would end up missing deadlines. Additionally, she was not utilizing her accommodation of taking a test in a limited distraction room because she could not remember to contact the DSS office one week prior to the test in order to secure the room. Staff members and Joan explored a personal digital assistant (PDA). After providing instruction on how to use the PDA, the student was given a PDA on a loan basis and all of her assignments, tests, quizzes, and papers were inputted into the device. Joan set up reminders for each area in order to receive a visual and auditory reminder of due dates. In particular, she set up reminders for her test date to go off one week in advance of the actual date so that she would remember to contact the DSS office to secure a testing room.

On a broader scale, career centers and disability support services offices have recognized a need for updated technology in their career centers, learning centers and support offices to meet the needs of students with traumatic brain injuries and spinal cord injuries. Through development of the CNI college consortium, the project has funded an institutional membership to Recordings for the Blind and Dyslexic to access texts in alternate format and a universally designed workstation in a career center lab to allow for adjustments for all users. Additionally speech-to-text and text-to-speech software for use in a career center lab and learning center were also purchased and installed.

Gaining Work Experience

Internship and work experience opportunities are instrumental in shaping the career path for individuals with disabilities. Students who engage in several career-related work experiences while in college, including internships, are able to secure employment more quickly after graduation, are more likely to be employed within their field of study, and are generally more satisfied in their work positions than graduates with no career related experience (Kysor & Pierce, 2000). Internships provide an excellent opportunity to assess the current and future support needs for individuals with disabilities (Getzel, Briel, & Kregel, 2000). Providing experiences for students to explore areas of interest, practice disclosing disability, determine effective accommodations, and make valuable connections with employers must be integrated into the college career planning process.

Some students with disabilities are able to self accommodate during their academic course of study but identify problem areas when applying knowledge and acquiring performance skills at a work site. For example, Stella was a graduate student with a brain injury and a substance abuse disorder who achieved a 3.0 GPA but received a failing grade on a clinical placement. She was unaware of her impulsive behaviors and inappropriate conversations with colleagues and clients. Program staff worked with Stella to understand her disability and how it impacted her interpersonal relationships, develop clear boundaries for professional interactions, and provide opportunities to practice these skills. Stella participated in a week long job shadow opportunity through the VCU Alumni Externship program. With support, Stella was able to disclose her disability to her supervisor and share the specific behavioral goals she was targeting for the week. Following this experience, program staff assisted in securing a work site in which Stella could practice her clinical skills for a longer time-period. The supervisor agreed to provide clear and regular feedback to the student.

Student Profile

Nick is a 26-year-old male who sustained a severe traumatic brain injury and multiple traumas as the result of a motor vehicle accident 5 years ago. At the time of injury, Nick was a college sophomore who studied biology. He also worked part-time as a veterinarian's assistant and was a member of the Army National Guard.

As a result of the injury, he was in a coma for eight days. He was hospitalized for one month and attended day rehabilitation for two months. Through cognitive retraining sessions, Nick identified some learning strategies that were effective for him in his daily life. These included reviewing information several times, developing acronyms to assist with recall, and using humor paired with associations.

Medical records and a neuropsychological evaluation conducted approximately nine months post-injury documented the following problems: loss of vision in the right eye, slowed motor reaction time, reduced stamina and fatigue, changes in memory, difficulties with word retrieval, problems with keeping track of time, and a reduction in self confidence. Reports also indicated distress associated with changes in his thinking and concerns about managing his temper. It was recommended that Nick return to work and school on a part-time basis.

Approximately one-year post injury Nick decided to return to school. To refresh his skills, he repeated a biology class at a community college. Then, he returned to the university and enrolled in four science courses. Nick failed all four classes and was placed on academic probation. The increased educational demands at the university proved difficult.

The next semester, Nick enrolled in a college orientation and study skills course. Significant to Nick was practical information about ways to improve reading comprehension, like identifying key information and taking notes. He also learned to schedule regular study times in a quiet place. Additionally Nick was referred to the ACE-IT! model at VCU during the middle of the semester. Program staff worked with Nick to identify useful campus resources, technology, and to develop time management strategies.

The supported education staff met with Nick and recommended that Nick register with the Disability Support Services Office. Nick was unaware that he potentially eligible for services and he was unaware of the process for receiving accommodations. The staff explained the accommodation process at the college level and gave Nick the contact information for the DSS office. After a meeting with the DSS coordinator, Nick was authorized to tape class lectures, take tests in an isolated area, receive books in an alternate format and received extended time for taking tests.

Although Nick was eligible for services, he felt intimidated by his professors and felt that they would judge him if he disclosed his disability. Nick and the staff discussed his feelings about having to disclose his disability to his professors. They also brainstormed ways to approach faculty. After they brainstormed, they role played these interactions. This helped to reduce Nick's anxiety over disclosure and gave him confidence to approach his professors. Finally, the staff introduced Nick to another student with a disability in order for Nick to have a support system.

Since Nick was overwhelmed with his schedule, staff informed him of the University's policies on add/drop and withdrawal. Nick was not aware of these policies. As he was well beyond the add/drop period, staff and Nick discussed the option of withdrawing from one course in which he was failing. Nick decided to withdraw from the course and concentrate on his remaining classes. Staff also reminded Nick of the upcoming priority registration date. They also discussed taking a reduced load and creating a balanced schedule that emphasized his areas of interests as well as his strengths.

To improve Nick's time management skills, Nick worked on developing a semester to do list, creating weekly work plans for academic assignments, and using a paper planner. Additionally, assignments were broken into manageable tasks and prioritized. Although the paper plan was somewhat effective, Nick needed prompting to look at the planner and he often overlooked items on his to do list as well. The use of a personal digital assistant (PDA) to use for time management was explored because the PDA has an alarm notification of upcoming events, which would help prompt Nick. Generalizing the use of this type of technology to the student's future career was discussed. Nick soon discovered that planning and structuring his time improved his attention and concentration, as well as increased his motivation to succeed.

Nick explored text-to-speech software for reading and writing as a way to compensate for his vision and memory issues. He found it useful to both hear and see the words on the screen. It was also helpful as a proofreading tool to listen to the papers he had written. With the utilization of accommodations, improved time management skills, and the use of technology, Nick was able to raise his grade point average.

To supplement his academic work and maintain a challenging schedule, Nick arranged a weekly volunteer position in a neurosurgery laboratory on campus. Through the assistance of the supported education program Nick later obtained a weeklong externship in the Pathology Department of a local hospital, entry-level summer employment, and a part-time lab technician position at a local blood service agency. Nick currently works in the whole blood components lab where he expresses platelets and separates plasma from red blood cells and puts his laboratory skills to practice.

By combining work experience with academic study, Nick was able to complete his first two years of study as a pre-health science major and was recently accepted into the clinical laboratory science medical program. Nick continues to utilize his accommodations, use his study and compensatory strategies, and maintains a strict schedule. He is currently pursuing his four-year degree.

CONCLUSION

Individuals with traumatic brain injury who enter postsecondary education face a number of issues and challenges that complicate the successful completion of their degree programs. Universities and colleges concerned with the retention rates of all students are beginning to explore strategies that enable students with disabilities to fully benefit from the educational experiences offered in higher education. Students with disabilities are one of several groups of diverse learners in college today. For these students, service options beyond the formal accommodation process established on campuses are needed. As universities and colleges explore the expansion of these service options, programs such as the one established at VCU need further study to document their effectiveness in meeting the unique learning needs of college students with traumatic brain injuries.

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Figure 1: Academic and Career Development Needs of Students with Disabilities Understand and accept disability Build self-esteem and confidence Learn about disability's impact on learning and in work environment Become familiar with compensatory strategies and assistive technology Learn about protections afforded and responsibilities under ADA Learn how to self-disclose and request accommodations Learn about academic and workplace supports through community resources Learn how to deal with insensitive faculty and employer comments and attitudes